Abstract

Background: The American Association for the Study of Liver Diseases has stated that fostering a “supportive environment for transsexual individuals seeking hepatology care” is an important goal. However, the landscape of transgender patients with cirrhosis is largely unknown. We aimed to assess the clinical characteristics of transgender patients with cirrhosis and quantify their outcomes.

Methods: We retrospectively analyzed a large national insurance registry (Optum) between 2008-2021, including adults with cirrhosis identified by validated ICD-9/10 codes. Liver transplant recipients were censored at transplant. Transgender patients were identified using a billing code definition validated in a large national insurance registry (89% true-positive rate and 0.05% false-negative rate). Inverse-probability treatment weighting (IPTW) was used to balance trans- and cis-gender populations on individual level characteristics, such as age, reported gender, Charlson comorbidity index, cirrhosis etiology and decompensation status. The outcome was all-cause mortality. Patients were censored at 3-years of follow-up.

Results: Among 55,741,658 adults in Optum, 28,672 (0.05%) were transgender. Among 282,106 adults with cirrhosis, 175 (0.06%) were transgender, with median follow-up of 2.4 years (IQR 0.9-4.2). Among patients with cirrhosis, trans- (vs. cis-) gender patients were younger (median age [IQR]: 62 [50-69] vs. 65 [57-72], p<0.001), more likely to have alcohol (105 [60%] vs. 143,175 [51%], p=0.02) or viral (65 [37%] vs. 79,406 [28%], p=0.01) as cirrhosis etiologies, diagnoses of anxiety (111 [63%] vs.106,031 [38%], p<0.001), depression (113 [65%] vs. 107,755 [38%], p <0.001), and HIV (14 [8%] vs. 3,971 [1%], p=0.001). Trans- (vs. cis-) gender patients had a similar likelihood of liver decompensation during follow-up (86 [51%] vs. 139,265 [49%], p=0.70), and undergoing liver transplantation (4 [2%] vs. 4,763 [2%], p=0.54). In IPTW-weighted survival analysis, probability of 3-year survival (72% vs. 70%, p=0.54) (Figure 1), and 3-year liver decompensation (33% vs. 40%, p=0.94) were similar. Trans- (vs. cis-) gender patients with cirrhosis spent more time receiving healthcare outside the home (median utilization per 100 days [IQR]: 3.1 days [0.9-9.9] vs. 1.5 days [0.3-5.1], p<0.001).

Conclusion: In this national study of insured persons with cirrhosis, the proportion of transgender patients was similar to the overall Optum population. We found that trans- (vs. cis-) gender patients have different clinical characteristics and greater healthcare utilization, but have similar liver decompensation, transplant, and mortality rates. These findings may help inform gender-inclusive hepatology care.